Nursing Elites

1. When the healthcare provider is determining the appropriate size of a nasopharyngeal airway to insert, which body part should be measured on the client?

• A. corner of the mouth to tragus of the ear
• B. corner of the eye to top of the ear
• C. tip of the chin to the sternum
• D. tip of the nose to the earlobe

Correct answer: D

Rationale: A nasopharyngeal airway is measured from the tip of the nose to the earlobe. This measurement ensures that the airway is of the correct length to reach the nasopharynx without being too long or too short. Choices A, B, and C are incorrect as they do not provide the appropriate measurement for selecting the correct size of a nasopharyngeal airway. The distance from the corner of the mouth to the tragus of the ear (Choice A) is used to measure for an oropharyngeal airway, not a nasopharyngeal airway. Similarly, the other choices (B and C) do not correlate with the correct measurement of a nasopharyngeal airway.

2. To remove hard contact lenses from an unresponsive client, what should the nurse do?

• A. Gently irrigate the eye with an irrigating solution from the inner canthus outward
• B. Grasp the lens with a gentle pinching motion
• C. Don sterile gloves before attempting the procedure
• D. Ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens

Correct answer: D

Rationale: When removing hard contact lenses from an unresponsive client, the nurse should ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens. This approach helps prevent scratching the cornea. Gently maneuvering the upper and lower eyelids assists in loosening the lens for easy removal. Options A, B, and C are incorrect because irrigating the eye, grasping the lens, or wearing sterile gloves are not recommended methods for removing hard contact lenses. It is crucial to handle the situation delicately to avoid causing harm or discomfort to the client.

3. Which of the following is not a function of parathyroid hormone?

• A. moving calcium from bones to the bloodstream
• B. inhibiting renal tubular reabsorption of phosphorus
• C. promoting renal tubular reabsorption of calcium
• D. enhancing renal production of vitamin D metabolites

Correct answer: B

Rationale: The correct answer is 'inhibiting renal tubular reabsorption of phosphorus.' Parathyroid hormone actually inhibits renal tubular reabsorption of phosphorus, making this choice the opposite of its function. Parathyroid hormone functions to move calcium from bones to the bloodstream (Choice A), promote renal tubular reabsorption of calcium (Choice C), and enhance renal production of vitamin D metabolites (Choice D). Therefore, all other choices are functions of parathyroid hormone except for the inhibition of phosphorus reabsorption.

4. While preparing a client for a bronchoscopy, a nurse notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client's necklace?

• A. Ask the client for permission to lock the necklace in the hospital safe
• B. Ask the client to remove the necklace and place it in the top drawer of the bedside table
• C. Ask the client whether the necklace is gold
• D. Ask the client to sign a release to free the hospital of responsibility if the necklace is damaged or lost during the procedure

Correct answer: A

Rationale: When a client has valuables such as jewelry, the nurse should ensure their safekeeping. It is appropriate for the nurse to ask the client for permission to lock the necklace in the hospital safe to prevent loss or damage. This option prioritizes the security of the necklace while allowing the client to make an informed decision. Asking the client to sign a release form does not guarantee the necklace's safety; it only releases the hospital from liability. Placing the necklace in a bedside table drawer does not provide adequate security as it is not as secure as a hospital safe. Inquiring whether the necklace is gold is irrelevant to safeguarding the jewelry during the procedure, as the primary concern is its safekeeping.

5. A client with major head trauma is receiving bolus enteral feeding. The most important nursing order for this client is:

• A. measure intake and output.
• B. check albumin levels.
• C. monitor glucose levels.
• D. increase enteral feeding.

Correct answer: A

Rationale: The correct action for a client with major head trauma receiving bolus enteral feeding is to measure intake and output (I&O). Enteral feedings are hyperosmotic agents that can cause fluid shifts. Monitoring I&O is crucial to assess fluid balance, ensuring that input matches output. Checking albumin levels (choice B) is important for assessing nutritional status but is not the immediate priority in this situation. Monitoring glucose levels (choice C) is also important but not as critical as measuring I&O in this context. Increasing enteral feeding (choice D) should only be done based on a healthcare provider's order after assessing the patient's condition, not as the most important nursing order at this time.

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